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2015 USA Boxing Michigan Junior Olympic Tournament
Fact Sheet
May 2 & 3, 2015 – Detroit, Michigan
COMPETITION DATES:
Saturday, May 2, 2015 and Sunday, May 3, 2015
LOCATION:
Downtown Boxing Gym
6445 E. Vernor Hwy
Detroit, MI 48207
WEIGH IN:
Saturday, May 2, 2015 7:00-9:00am
Sunday, May 3, 2015 7:00-9:00am
There will be an area set up for all USA Boxing Junior Olympic Tournament Staff to check-in and verify
participants’ information with officials. You MUST provide a current passbook to participate. NO BOOK = NO
BOXING! All participants must provide valid proof of U.S. citizenship (birth certificate, U.S. Passport, etc.)
PHYSICALS:
Saturday, May 2, 2015 10:00am
Sunday, May 3, 2015 10:00am
COMPETITION BEGINS:
Saturday, May 2, 2015 12:00pm
Sunday, May 3, 2015 12:00pm
REGISTRATION DEADLINE:
Thursday, April 30, 2015
ENTRY FEES:
$5.00 by deadline, $10.00 after April 30, 2015
(Late registrants are NOT guaranteed acceptance.)
ADMISSION:
$15.00/day or $25.00/two-day pass
TITLE SPONSOR:
PRESENTING SPONSOR:
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2015 USA Boxing Michigan Junior Olympic Tournament
May 2 & 3, 2015 – Detroit, Michigan
Local Housing Information
Hilton Garden Inn
Detroit Downtown
351 Gratiot Avenue
Detroit, MI 28226
313.967.0900
To make your reservation, please call 1.800.HILTONS.
Group code: Downtown Boxing Gym Youth Program
$119/night + tax
Valet parking is currently $22/night
Guestroom Amenities:
• In room hospitality center featuring refrigerator, microwave and coffee maker
• Complimentary high speed wireless internet
• 27” HD LCD Flat Screen Television
• IPOD /MP3 Docking stations in rooms
• Spacious work desk with ergonomic Mirra® work chair by Herman Miller
• Individual climate control
• Hairdryer, Iron & Ironing Board
• Neutrogena Amenities
General Hotel Amenities:
• Two onsite restaurants
• 24 hour business center
• Onsite pool and fitness center
• Location within walking distance of many of Detroit’s top restaurants, shops, entertainment &
sporting venues
Reservations must be made by April 20, 2015, in order to receive the discounted room rate.
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JUNIOR ATHLETES’ REQUIREMENTS
1.
USA BOXING COMPETITION PASSBOOK
IF YOU DO NOT HAVE YOUR PASSBOOK AT REGISTRATION YOU WILL NOT BE
ENTERED INTO THE TOURNAMENT DRAW!! REGISTRATION IS NO LONGER
AVAILABLE AT CHECK-IN. YOU MUST REGISTER PRIOR TO THE EVENT!
2.
PROOF OF U.S. CITIZENSHIP
A COPY OR PICTURE OF YOUR ORIGINAL BIRTH CERTIFICATE, GOVERNMENT
ISSUED U.S. PASSPORT, OR DRIVER’S LICENSE WILL BE ACCEPTED.
3.
BOXING EQUIPMENT
USA BOXING APPROVED HEADGEAR, MOUTHGUARD (NO RED), UNIFORMS,
BOXING BOOTS
SUBMISSION DEADLINE: THURSDAY, APRIL 30, 2015
SUBMIT ALL APPLICATIONS TO:
Downtown Boxing Gym
4760 St. Aubin Street
Detroit, MI 48207
or via email at
[email protected]
For questions, please call 313.334.9600
3
JUNIOR ATHLETE ENTRY FORM
2015 USA BOXING MICHIGAN JUNIOR OLYMPIC TOURNAMENT
OFFICIAL ATHLETE ENTRY FORM
LBC Tournament Sanctioned by USA Boxing:
MICHIGAN STATE TOURNAMENT
Association, Inc.
REGIONAL Tournament Sanctioned by USA Boxing:
Association, Inc.
NATIONAL Tournament Sanctioned by USA Boxing:
Association, Inc.
PLEASE CHECK APPROPRIATE BOX:
NAME:
Weight Class:
LBC:
Region Name & No.:
MALE
Your Age As Of May 3, 2015:
Birth Date:
Address:
Passbook Validation:
Street
Phone #:
FEMALE
City
State/Zip
Cell Phone #:
Fax:
Personal Coach Name & Phone:
Do you wear Dental Braces? Yes
(2015)
Email Address:
Your Personal Boxing Club:
No
If yes you must comply with Article 2, 102.6 (g) USA Boxing, Inc. rules.
WAIVER/WARNING
IN CONSIDERATION OF YOUR ACCEPTING THIS ENTRY, I HEREBY, FOR MYSELF, MY HEIRS, EXECUTORS ADMINISTRATORS
AND ASSIGNS WAIVE AND RELEASE ANY AND ALL RIGHTS TO ANY CLAIM FOR DAMAGES I MAY OR MIGHT HAVE AGAINST
UNITED STATES AMATEUR BOXING (USA BOXING), ANY SANCTIONING LOCAL BOXING COMMITTEE OF USA BOXING AND ALL
SPONSORS AND VENUE OWNERS, OR THE OFFICERS, SUB-COMMITTEES AGENTS, REPRESENTATIVES AND ASSIGNS OF
THESE ENTITIES, FOR ANY INJURY OR DAMAGE SUFFERED BY ME DURING MY PARTICIPATION IN, AND/OR ARISING FROM
TRAVELING TO AND/OR RETURNING FROM THE BELOW LISTED TOURNAMENTS.
The USA Boxing Local Championship Tournament at:
Detroit, MI
Date:
May 2 & 3, 2015
The United States Amateur Boxing Regional Tournament at:
Date:
The United States Amateur Boxing National Tournament at:
Date:
AGREE TO ABIDE BY THE RULES OF UNITED STATES AMATEUR BOXING. I FULLY UNDERSTAND THAT I ASSUME ALL
RESPONSIBILITY FOR ANY INJURY OR DAMAGE THAT I MAY INCUR IN THESE BOXING BOUTS. I UNDERSTAND AND AGREE
THAT MEDICAL OR OTHER SERVICES RENDERED TO ME BY OR AT THE INSISTANCE OF ANY OF THE NAMED PARTIES IS NOT
AN ADMISSION OF LIABILITY TO PROVIDE OR CONTINUE TO PROVIDE ANY SERVICES AND IS NOT A WAIVER BY ANY OF SAID
PARTIES OF ANY RIGHT OR RIGHTS HEREUNDER.
I CERTIFY THAT I HAVE HAD NO INJURIES TO MY HANDS, NEITHER FRACTURES NOR BROKEN BONES, WITHIN THREE MONTHS
PRECEDING THE DATES OF THIS ENTRY FORM, AND KNOW OF NO OTHER INJURIES TO THE HEAD, CONCUSSION, FAINTING
SPELLS, AND WILL NOTIFY BOXING OFFICIALS IMMEDIATELY SHOULD ANY OF THESE INJURIES AND CONDITIONS BE
EXPERIENCED IN THE FUTURE.
IN ADDITION, I ALSO UNDERSTAND AND APPRECIATE THAT PARTICIPATION IN THE SPORT OF BOXING CARRIES A RISK TO ME
OF SERIOUS INJURY, INCLUDING PERMANENT PARALYSIS OR DEATH; I VOLUNTARILY AND KNOWINGLY RECOGNIZE, ACCEPT
AND ASSUME THIS RISK.
Signed:
Date:
Participant’s Full Name
Signed:
Date:
Parent(s) or Guardian(s)
REQUIRED FOR ALL PARTICIPANTS
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2015 USA Boxing Michigan Junior
Olympic Tournament
Release To Compete With Braces
USA Boxing Rule 102.6 (4) (g) Boxers who wish to compete with braces are required to have attached
to their passbooks a completed Release To Compete With Braces form. This form requires the written
approval of their dentist, parents and/or guardian (if under 18 years of age) and a dentist-molded
mouthpiece. This includes upper and/or lower braces. Boxers competing with braces waive the right to
dental coverage under the USA Boxing insurance program.
I understand the above rule and give my permission for ________________________________ to
compete in amateur boxing.
(Boxer’s name)
Dentist Approval:
___________________________________
Print Name
__________________________________
Signature
___________________________________
Date
__________________________________
State License Number
Parent or Legal Guardian Approval (if boxer is a minor):
_____________________________
Print Name
____________________________
Signature
____________
Date
____________________________
Signature
____________
Date
Athlete:
_____________________________
Print Name
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USA BOXING ATHLETE/NON ATHLETE CODE OF CONDUCT
Athlete/Non-Athlete Code of Conduct
Outlined below is the USA Boxing Code of Conduct
I understand that my compliance with the Code is a requirement for my participation in USA Boxing
events. I recognize that my participation in this event is an honor and privilege. I also recognize that
this Code does not establish a complete set of rules that prescribes every aspect of appropriate
behavior. Further, I:
1. Will act in a manner consistent with the spirit of fair play and responsible conduct;
2. Will recognize, respect and adhere to the authority of USA Boxing’s appointed coaches and team
leaders;
3. Will attend all team functions, to include meetings, practices, press conferences, competitions,
etc. unless excused or otherwise instructed by the team leader or USA Boxing’s designee;
4. Will comply with USA Boxing and the United States Olympic Committee (USOC) uniform
requirements;
5. Will be within 5% pounds of my competition weight prior to competition or 8% pounds within
my competition weight for a training camp 30 days out from competition;
6. Will adhere to all curfews established by the team leader or USA Boxing’s designee;
7. Will maintain an appropriate level of fitness to promote optimal athletic performance;
8. Will make every effort to perform to the best of my abilities;
9. Will refrain from the use of performance-limiting drugs, including, but not limited to, tobacco
and alcohol;
10. Will refrain from using any substance on the Olympic Movement Anti-Doping Code or
Association Internationale de Boxe Amateur (AIBA) banned substance list, as enforced by
WADA and USADA, and will abide by the drug testing procedures of USADA, WADA, and the
USOC;
11. Will abide by the policies and rules established by USA Boxing, the USOC and the Association
International De Boxe Amateur (AIBA);
12. Will respect others, including my teammates, coaches, competitors, officials and spectators;
13. Will not engage in, nor tolerate, any form of verbal, physical or sexual abuse;
14. Will respect the property of others;
15. Will refrain from profanity and derogatory language that would reflect negatively on myself and
USA Boxing;
16. Will refrain from illegal or inappropriate behavior that would detract from a positive image of
myself and USA Boxing;
17. Will refrain from engaging in any behavior that could detract from my ability, or my teammates’
ability, to perform optimally;
18. Will maintain a positive attitude and act in a way that will bring honor to myself, the team, USA
Boxing and the United States of America;
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19. Will limit socialization with members of the opposite sex to public areas, exceptions being
immediate family members, members of the USA delegation and/or other times as approved by
the team leader;
20. Will remember that I am an ambassador for USA Boxing, my country and the Olympic
movement; and
21. Will cooperate with USA Boxing’s grievance process and Judicial Committee requests.
Any member present during any violation of the Code of Conduct should leave the area immediately or
be considered a participant by choice.
Disciplinary Procedures and Penalties
Failure to comply with the Code of Conduct set forth in this document for USA Boxing may result in
disciplinary action in accordance with the penalties outlined in this agreement.
Penalties could include:
1.
Temporary or permanent termination of USA Boxing membership.
2.
Suspension from USA Boxing activities for a specified period.
3.
For National Team members:
a.
Immediate dismissal from team and return home at athlete’s expense.
b.
Withholding of a portion or all of any stipend(s) received from USA Boxing, USOC, etc.
Following any disciplinary action by USA Boxing, the disciplined member has a right to a hearing by
the Judicial Committee, if requested in writhing with the statute of limitations, and submitted with the
filing fee.
Any appeal taken for disciplinary action rendered in an emergency hearing shall be to USA Boxing’s
CEO and will be conducted in accordance with Article XIV, Section 214.12 of USA Boxing’s
Constitution and By-laws
Acceptance
I pledge to uphold the spirit of this Code, which offers a general guide to my conduct as a participant in
a USA Boxing event. I agree to follow the USA Boxing Grievance Procedures if I am charged with
violation of the Code. I have familiarized myself with the Code and understand that my acceptance of it,
as signified by my signature below, is a condition of my membership in this USA Boxing event.
Participant Name (Printed)
Date
Participant Name (Signature)
2015 USA BOXING MICHIGAN JUNIOR OLYMPIC TOURNAMENT
Name of Event
Witness
Rev.03/30/15
7
FORM MUST BE FILLED OUT IN ITS ENTIRETY
MEDICAL TREATMENT FORM
TO:
2015 USA Boxing Michigan Junior Olympic Tournament Participants
FROM:
USA Boxing Events Department
SUBJECT:
Medical Treatment Form
United States Amateur Boxing’s insurance company requires a signed medical treatment form either
authorizing emergency medical treatment or not authorizing medical treatment for all participating
individuals. Participants under 18 years of age, are required to have parental / guardian signatures
as well.
Please complete and sign the attached form. Be sure to indicate whether treatment is approved or not
approved.
Thank you for your assistance with this matter. Please do not hesitate to contact the Events Department
at USA Boxing Headquarters at (719) 866-2307 if you have any questions.
MEDICAL TREATMENT FORM
_____ I AUTHORIZE a duly appointed representative of United States Amateur Boxing, Inc., to consent to
emergency medical treatment during my participation in USA Boxing’s sanctioned event.
_____ I DECLINE to authorize consent for emergency medical treatment during my participation in USA
Boxing’s sanctioned event for the following reasons:
If you marked DECLINE, please mark one of the following:
_____ Religious
_____ Personal
_____ Other:
Signed:
(Athlete Signature)
Date:
Signed:
Date:
(Parent/Guardian Signature for athletes under 18 yrs.)
Rev.03/30/15
8
FORM MUST BE FILLED OUT IN ITS ENTIRETY
DECLARATION OF NON-­‐PREGNANCY FOR GIRLS BOXERS AGED UNDER 18 (EIGHTEEN) Date: Place: Name of Competition: I,____________________________ , am one of the parents / legal caretaker of ,____________________ (insert name of the Boxer) and declare, on her behalf, that she is not pregnant. I understand the seriousness of this statement and accept full responsibility for it. In the case that this declaration is subsequently shown to be inaccurate or untrue and ___________________________, (insert name of the Boxer) suffers any related injury or damage during the competition, I on behalf of_____________________________, (insert name of the Boxer), her heirs, executors and administrators, waive and release any and all claims for damages she may have against USA Boxing (including its officials and employees), the organizers of the competition (including the Organizing Committee and the Host Federation) and the Competition Venue owners for such injury or damage. Signature of one of the Parents / Legal Caretaker _____________________________________ Acknowledged by _____________________________________ [Signature of the Boxer] 9
PREP ATHLETE ENTRY FORM 2015 USA BOXING MICHIGAN JUNIOR OLYMPIC TOURNAMENT
OFFICIAL ATHLETE ENTRY FORM
LBC Tournament Sanctioned by USA Boxing:
MICHIGAN STATE TOURNAMENT
Association, Inc.
REGIONAL Tournament Sanctioned by USA Boxing:
Association, Inc.
NATIONAL Tournament Sanctioned by USA Boxing:
Association, Inc.
PLEASE CHECK APPROPRIATE BOX:
NAME:
Weight Class:
LBC:
Region Name & No.:
MALE
Your Age As Of December 31, 2015:
Birth Date:
Address:
Passbook Validation:
Street
Phone #:
FEMALE
City
State/Zip
Cell Phone #:
Fax:
Personal Coach Name & Phone:
Do you wear Dental Braces? Yes
(2015)
Email Address:
Your Personal Boxing Club:
No
If yes you must comply with Article 2, 102.6 (g) USA Boxing, Inc. rules.
WAIVER/WARNING
IN CONSIDERATION OF YOUR ACCEPTING THIS ENTRY, I HEREBY, FOR MYSELF, MY HEIRS, EXECUTORS ADMINISTRATORS
AND ASSIGNS WAIVE AND RELEASE ANY AND ALL RIGHTS TO ANY CLAIM FOR DAMAGES I MAY OR MIGHT HAVE AGAINST
UNITED STATES AMATEUR BOXING (USA BOXING), ANY SANCTIONING LOCAL BOXING COMMITTEE OF USA BOXING AND ALL
SPONSORS AND VENUE OWNERS, OR THE OFFICERS, SUB-COMMITTEES AGENTS, REPRESENTATIVES AND ASSIGNS OF
THESE ENTITIES, FOR ANY INJURY OR DAMAGE SUFFERED BY ME DURING MY PARTICIPATION IN, AND/OR ARISING FROM
TRAVELING TO AND/OR RETURNING FROM THE BELOW LISTED TOURNAMENTS.
Detroit, MI
The USA Boxing Local Championship Tournament at:
Date: May
The United States Amateur Boxing Regional Tournament at:
Date:
The United States Amateur Boxing National Tournament at:
Date:
2 & 3,2015
AGREE TO ABIDE BY THE RULES OF UNITED STATES AMATEUR BOXING. I FULLY UNDERSTAND THAT I ASSUME ALL
RESPONSIBILITY FOR ANY INJURY OR DAMAGE THAT I MAY INCUR IN THESE BOXING BOUTS. I UNDERSTAND AND AGREE
THAT MEDICAL OR OTHER SERVICES RENDERED TO ME BY OR AT THE INSISTANCE OF ANY OF THE NAMED PARTIES IS NOT
AN ADMISSION OF LIABILITY TO PROVIDE OR CONTINUE TO PROVIDE ANY SERVICES AND IS NOT A WAIVER BY ANY OF SAID
PARTIES OF ANY RIGHT OR RIGHTS HEREUNDER.
I CERTIFY THAT I HAVE HAD NO INJURIES TO MY HANDS, NEITHER FRACTURES NOR BROKEN BONES, WITHIN THREE MONTHS
PRECEDING THE DATES OF THIS ENTRY FORM, AND KNOW OF NO OTHER INJURIES TO THE HEAD, CONCUSSION, FAINTING
SPELLS, AND WILL NOTIFY BOXING OFFICIALS IMMEDIATELY SHOULD ANY OF THESE INJURIES AND CONDITIONS BE
EXPERIENCED IN THE FUTURE.
IN ADDITION, I ALSO UNDERSTAND AND APPRECIATE THAT PARTICIPATION IN THE SPORT OF BOXING CARRIES A RISK TO ME
OF SERIOUS INJURY, INCLUDING PERMANENT PARALYSIS OR DEATH; I VOLUNTARILY AND KNOWINGLY RECOGNIZE, ACCEPT
AND ASSUME THIS RISK.
Signed:
Date:
Participant’s Full Name
Signed:
Date:
Parent(s) or Guardian(s)
REQUIRED FOR ALL PARTICIPANTS
10
COACHES’ REQUIREMENTS
1. PROOF OF 2015 USA BOXING MEMBERSHIP AND PROOF OF USAB COACHES
CERTIFICATION
USA BOXING RED COACH’S PASSBOOK
2. TOURNAMENT ENTRY FORMS
NON-ATHLETE ENTRY FORM, CODE OF CONDUCT, COACHES CERTIFICATION
FORM
SUBMISSION DEADLINE: THURSDAY, APRIL 30, 2015
SUBMIT ALL APPLICATIONS TO:
Downtown Boxing Gym
4760 St. Aubin Street
Detroit, MI 48207
or via email at
[email protected]
For questions, please call 313.334.9600
11
NON-ATHLETE ENTRY FORM
NON-ATHLETE ENTRY FORM
Name of Competition: 2015 USA BOXING MICHIGAN JUNIOR OLYMPIC TOURNAMENT
Name: LBC#: Region#: Address: Street
City
Phone #:
Validation #:
State
Zip
Date of Birth:
(2015)
Check one:
Official:
Coach:
Other:
(If other, what capacity)
Coaches and officials please list current level: WAIVER AND RELEASE AND ASSUMPTION OF RISK
IN CONSIDERATION OF ME BEING ALLOWED TO PARTICIPATE IN A NON-ATHLETE
CAPACITY, AND ACCEPTANCE OF THIS ENTRY FORM IN A UNITED STATES AMATEUR
BOXING COMPETITION, I AGREE:
1.
2.
3.
I understand the nature of United States Amateur Boxing, Inc. activities and my experience and capabilities and believe I am
qualified to participate in such activity. I further acknowledge that I am aware the activity will be conducted in facilities
open to the public during the activity. I further agree and warrant that if I believe conditions to be unsafe, I will immediately
discontinue further participation in the activity.
I FULLY UNDERSTAND that: (a) United States Amateur Boxing, Inc. activities involve risks and dangers of SERIOUS
BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH (“Risks); (b) these Risks and
dangers may be caused by me or the actions or inactions of others participating in the activity, the condition in which the
activity takes place, or THE NEGLIGENCE OF THE “RELEASEES” NAMED BELOW; (c) there may be other risks and
social and economic losses either known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND
ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES incurred as a
result of my participation in these activities.
I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE
AND HOLD HARMLESS the United States Amateur Boxing, Inc., it’s clubs and LBC’s, their respective administrators,
directors, agents, officers, volunteers, and employees, other participants, any sponsors, advertisers, and if applicable, owners
and lessors of premises on which the activities take place (each considered one of the “Releasees” herein) from all liability,
claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence of
the “Releasees” or otherwise, including negligent rescue operations and further agree that if, despite this release, I, or
anyone on my behalf makes a claim against any of the Releasees named above, I WILL INDEMNIFY, SAVE AND
HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES, ATTORNEY FEES,
LOSS LIABILITY, DAMAGE OR COST ANY MAY INCUR AS THE RESULT OF ANY SUCH CLAIM.
Participant Name (Print)
Date
Participant Name (Signature)
Date
Rev.03/30/15
12
FORM MUST BE FILLED OUT IN ITS ENTIRETY
COACHES CERTIFICATION FORM
Coaches Certification Form
Date ______________________________
LBC ______________________________
2015 USA BOXING MICHIGAN JUNIOR OLYMPIC TOURNAMENT
To Coach at:
Year / Event
I certify that I, ________________________________________ am a Level _________
Coach and competent to work in an athlete’s corner at the tournament listed above.
________________________________
2015 USA Boxing Registration #
Last Coaches Clinic Attended
Level
Date
Location
Coach Signature
Rev.03/30/15
Date
FORM MUST BE FILLED OUT IN ITS ENTIRETY
13
OFFICIALS’ REQUIREMENTS
1. PROOF OF 2015 USA BOXING MEMBERSHIP
USA BOXING BLUE OFFICIAL’S PASSBOOK
2. PROOF OF USAB OFFICIALS’ CERTIFICATION
CLINIC INFORMATION: OCN NUMBER, DATE, LOCATION
3. 2015 TOURNAMENT ENTRY FORMS
NON-ATHLETE ENTRY FORM, OFFICIALS CODE OF ETHICS, CODE OF CONDUCT,
OFFICALS REFERRAL FORM
SUBMISSION DEADLINE: THURSDAY, APRIL 30, 2015
SUBMIT ALL APPLICATIONS TO:
Downtown Boxing Gym
4760 St. Aubin Street
Detroit, MI 48207
or via email at
[email protected]
For questions, please call 313.334.9600
14
Official’s Code of Ethics
Outlined below is the USA Boxing Official’s Code of Ethics. I understand that my compliance with the
Code is a requirement for my participation in a USA Boxing event as an Official. An Official is defined
as a referee, judge, timekeeper, computer tech, clerk, or weight master. I also recognize that this Code
does not establish a complete set of rules that prescribes every aspect of appropriate/inappropriate
behavior.
1. I will act in a manner consistent with the spirit of fair play and responsible conduct. Neutrality is of the
utmost concern.
2. I will comply 100% with the neutrality rule and not officiate any bout that involves a participant from my
current or former Region(s). I must notify the Ring Captain of any conflict so that the next neutral
official can take my place. The only person that is authorized to make an exception, and only if there is
a shortage of officials, is the Ring Captain. [USA Boxing rule 107.4 (6) Conflict of Interest Rule]
3. I will remove myself from working a bout if I'm assigned to work a bout where a conflict exists such that
there is a bias or partiality to any of the participants, i.e., including, but not limited to being related to or
having worked in a coaching/training capacity with any of the participants. We MUST attempt to avoid
any situation where it might APPEAR that a boxer has an advantage by your involvement as an official
on that bout.
4. If I am related to a boxer or if there is a boxer to whom I am very close that is competing in this event I
must eliminate myself from officiating in this boxer's weight class.
5. I am here to work as an Official and only in the capacity of an Official. I will not work as a coach or as a
second for the duration of this tournament.
I acknowledge that my failure to comply with the Official's Code of Ethics set forth in this document by
USA Boxing may result in my immediate dismissal as an official from this event and that additional
disciplinary actions may be applied against me for such inappropriate behavior.
I pledge to uphold the spirit of this Code, which offers a general guide to my conduct as a participant as an
Official in this USA Boxing event.
Name (Printed) ___________________________________
Date _________________
Name (Signature) _________________________________
Region(s): ____________
Name of Event: __2015 USA BOXING MICHIGAN JUNIOR OLYMPIC TOURNAMENT______
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OFFICIALS REFERRAL FORM
Officials Referral Form
Date ______________________________
To Chief of Officials for:
LBC ______________________________
2015 USA Boxing Michigan Junior Olympic Tournament
Year / Event
This is to certify that ________________________________________ is a Level _________
Official and competent to work the tournament listed above.
________________________________
2015 USA Boxing Registration #
I will: _______ _______ _______ _______
Referee
Judge Timer
C/T
Last Five Regional or National Events Worked
(Minimum Level II for a National Tournament):
Year
Event
Location
LBC President:
Signature
Date
Signature
Date
LBC Chief of Officials:
Rev.03/30/15
16
FORM MUST BE FILLED OUT IN ITS ENTIRETY